Medication Benefits 

Your medication benefits cover prescription drugs, over-the-counter items, and more.  

Here’s how Highmark Health Options Duals (HMO SNP) medication benefits work.

Formulary (Drug List) 

The prescription drugs Highmark Health Options Duals covers are shown in a formulary, also called a drug list. Your formulary shows which Medicare Part D prescription drugs are covered under your Medicare Part D benefits. It also stays updated with any drug restrictions. 

Formulary Resources and Documents

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Medication Therapy Management (MTM) Program

Our MTM Program is a no cost program that helps you get the most out of your medication. If you choose to join the MTM Program, a pharmacist or other health care expert will review all your medications, then talk with you about: 

  • What you’re taking 
  • How much your drugs cost 
  • Over-the-counter medications 
  • Any problems or questions you have 
  • A written summary with next steps, if needed 

 

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Over-the-Counter (OTC) Benefit 

Some medicine is available without a prescription. Your Highmark Health Options Duals benefit includes an allowance of $208 per month to spend on OTC medicine and medical supplies, like:

  • Vitamins
  • First aid supplies like Band-Aids
  • Dental products like denture cleaner and toothbrushes
  • Incontinence products like Depends
  • Topical ointments like Aspercreme
  • Pain medications like Tylenol or Advil
  • Stop smoking items

You can place your orders online, by phone, or by mail. The monthly allowance will be automatically loaded onto a FlexCard by Mastercard. Treat it like a debit card and use it anywhere that accepts Mastercard. Unused amounts will roll over to the next month.

Need help?

  • Call 1-833-623-2619, Monday–Friday, 8 a.m.–8 p.m.
  • Visit the My Healthy Flex website  to view balance, purchase history, and more.
  • Download the myTotal Benefits app from the Apple App Store or Google Play. Use this app to scan products while shopping to see if the product is eligible for purchase using your FlexCard.

 

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Prescription Drugs 

Your Highmark Health Options Duals prescription drug benefit includes both Medicare Part D and Medicaid prescription drug coverage. When your doctor writes a prescription, your drug coverage includes access to pharmacies where you live, a broad drug list, and mail-order service. Remember to show your Highmark Health Options Duals card each time you visit your pharmacy. 

You're covered for all $0 prescription drug copays: 

  • $0 copay on prescriptions.
  • $0 copay during all prescription drug benefit phases. 

Note: Applies to Part D drugs only. 

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Step Therapy 

Your Highmark Health Options Duals prescription drug benefits follow rules and coverage limits called step therapy for medically administered drugs. In some instances, like injectables or biologics, step therapy has you try a preferred drug first before nonpreferred drugs are covered. 

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Prescription Transitions 

If your drug is not on the formulary (drug list) or is restricted, here are some things you can do to help avoid missing doses.

In some cases, your D-SNP can offer you a temporary drug supply if your drug isn’t on the drug list or if it’s restricted. This can give you and your doctor time to review other options or ask for a medication exception. 

To be considered for a temporary supply, some rules must be met, like:

  • The drug you’ve been taking is no longer on your D-SNP drug list.
  • The drug you’ve been taking is restricted in some way.
  • As a new or continuing D-SNP member, you may be taking drugs that are not on our formulary.
  • You may be taking a drug that is on your D-SNP drug list but your ability to get it is limited.

As an example, you may need a prior authorization from us before you can fill your prescription. If this happens, you should talk to your doctor to decide if you should consider a covered drug or request a formulary exception so that the drug you take gets covered. 

 

In some cases, your drug may get covered during your first 90 days as a Highmark Health Options Duals member. 

                                                                                

As examples, the following members can get a temporary supply of each drug that’s not on our formulary or if the ability to get your drugs is limited: 

 

If You Were a D-SNP Member Last Year and Aren’t In a Long-Term Care Facility

For one time only, your D-SNP will cover a temporary supply of your drug during the first 90 days of the calendar year if your claims history shows you were previously on the drug and Highmark Health Options Duals made formulary changes from the previous year that negatively impacted you. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of the calendar year.

 

If You’re a New D-SNP Member and Aren’t In a Long-Term Care Facility

For one time only, your D-SNP will cover a temporary supply of your drug during the first 90 days of your membership. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 30 days during the first 90 days of your enrolling in your D-SNP, beginning on the effective date of coverage.

 

If You’re a New D-SNP Member and Live In a Long-Term Care Facility

For one time only, your D-SNP will cover a supply of your drug during the first 90 days of your membership. This temporary supply will be for a maximum of 31 days, or less if your prescription is written for fewer days, with refills provided if needed up to a total of 31 days during the first 90 days of your enrolling in your D-SNP, beginning on the effective date of coverage.

 

If You’ve Been a D-SNP Member For More Than 90 Days, Live In a Long-Term Care Facility and Need a Supply Right Away

Your D-SNP will cover one 31-day supply, or less if your prescription is written for fewer days while an exception or prior authorization is requested. This is in addition to the above long-term care transition supply.

 

If your drug isn’t on your D-SNP drug list or is restricted, you can change to another drug.

 

You can call Member Services at 1-855-401-8251 (TTY: 711 or 1-800-232-5460) to ask for a list of covered drugs that treat the same medical condition. Sharing this list with your doctor can help you both decide if you should make medication changes.  

 

You and your doctor can request an exception by asking Highmark Health Options Duals to cover the drug or remove restrictions from the drug. If your doctor agrees that you have medical reasons that justify asking for an exception, he or she can help you make the request. 

 

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